Care provided at night is the soft underbelly of any care delivery system. Disease onset and progression knows no diurnal boundary. However, resource allocation in terms of care delivery is frugal compared to day time care. A PubMed search was done to ascertain any studies pertaining to cross cover work done by hospitalists during overnight hours. No such studies were found.
This observational study evaluated the alphanumeric page characteristics; number of admissions, consultations as well as patients seen in person as part of cross coverage and lastly ascertained the number as well as the characteristics of the orders placed by the Hospital Medicine physicians between 1900 to 0700 hours for a period of 14 night shifts. List of overnight orders was obtained from EPIC EMR as well as a daily log for overnight admissions and alphanumeric pages was collected. HM providers were paged at the end of the shift to ascertain number of patients seen in person and the reason for evaluating in response to a cross cover page. Study was conducted at the 2 downtown campuses of Swedish Medical Center which is a tertiary care provider. Swedish Hospital Medicine group is a well established group with over 30 providers and dedicated team of 8 night time providers. The study protocol was approved by Swedish IRB(4975S10).
Over the study period 1)14,872 orders were entered, that is a little over 1000 orders written per night; 2) Admissions 287 (81%), Consults 13 (4%), Patients evaluated as part of cross cover duties 52 (15%); 3)Pages 1542;Pages dealing with change in clinical status 25%. Over 70% of the cross cover encounters were seen in response to a nurse notification of change in vital signs or as a direct request from the RN. The rest were seen as part of code blue or rapid response team. Percentage of orders dealing with medications 24%, nursing requests 25% and tests 28%. Verbal orders 3%. The majority of pages were received before 1 AM with an up tick in the page volume towards the end of the shift.
We believe this is the first observational study to evaluate nocturnist work flow. A large portion of a nocturnist’s job is to evaluate new patients. It is not uncommon to evaluate patients in person as part of cross cover duties. However as 85% of the pages concerning previously admitted patients did not require any in person evaluation and this raises the possibility of remote cross coverage in an EMR/CPOE environment. Based upon the number of pages per night, interruptions are frequent at night. Given paucity of night time resources we feel that evaluation of night time services should be foremost in any care delivery system design or redesign. We did not observe the uncompensated time spent entering orders and answering nurse queries for patients not requiring in person evaluation. This night shift study provides a substrate for formulating new hypothesis and designing subsequent studies to evaluate night time work.
Table 1Night Patient Encounter Breakdown Total 352
|Admissions 287 (81%)|
|Consults 13 (4%)|
|Previously Admitted Patients Evaluated as part of Cross Cover 52 (15%)|
Table 2Breakdown of Orders Placed by Nocturnists over 14 Nights Total Orders 14,872
|Nursing Orders 25%|
|Admission, Transfer,Code Status, Diet 10%|
|Therapy, Pharmacist communication, miscellaneous 10%|
|Verbal Orders 3%|
To cite this abstract:Watson A, Sachdeva S, Spinelli T. Hospital Medicine Patient Cross Cover and Work Evaluation During Night Shifts. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97680. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/hospital-medicine-patient-cross-cover-and-work-evaluation-during-night-shifts/. Accessed July 20, 2019.